In 2016, the emergency medicine world was introduced to the system called HEART Pathway, a clinical protocol and decision support platform that uses objective data to risk stratify chest pain patients.
HEART Pathway was developed by a group of Wake Forest Baptist scientists led by Simon Mahler, MD, a professor of emergency medicine at Wake Forest School of Medicine. Since its release, HEART Pathway has been adopted by all of the hospitals in the Atrium Health Wake Forest Baptist system and is seeing increasing acceptance in emergency departments nationwide.
The algorithm is designed to enhance clinical decision-making about which chest pain patients need advanced diagnostic procedures such as angiography and stress testing and which can be safely sent home without those costly, time-consuming and frequently unnecessary measures.
Clinical trials have firmly established the safety and effectiveness of the HEART Pathway evaluation method. As positive data has accumulated in follow-up studies, the system has become more and more accepted in EDs around the country and the developers have added new features and refined the existing ones, resulting in an even more powerful system. It is the epitome of a learning health system, where new information from research contributes to ongoing improvements. “The concept of the academic learning health system is a health system that collects data on things that have benefited our patients and then learns from that and changes, and that is precisely what we’ve done with HEART Pathway,” says Mahler.
Onward and Upward on the HEART Pathway
Mahler shared the many important advances that have brought HEART Pathway to where it is today.
First, commercialization and scalability have made the system more widely available and have increased awareness of its many advantages. Wake Forest Baptist helped establish a company called Impathiq to market HEART Pathway. “When we set out to build a scalable solution that would integrate into the electronic health record, that’s when the idea of commercialization came about in partnership with Wake Forest Innovations, and we were able to spin off a company to do that,” says Mahler. Impathiq offers a comprehensive approach incorporating integrated decision support. It includes the HEART Pathway clinical algorithm, which uses objective clinical data to risk stratify patients with chest pain. HEART Pathway plug-ins are available for quick activation on America’s top electronic medical platforms, including Epic, Cerner and Apple iOS.
“High-sensitivity troponins really add value to the HEART Pathway. They are better able to detect patients that are having myocardial injury, so we’re less likely to miss a patient that’s having a heart attack. We are probably sending more patients home now with the high-sensitivity troponins incorporated into our HEART Pathway then we were previously.”Impathiq also offers a state-of-the-science high-sensitivity troponin platform. The protocol is compatible with assays from the leading diagnostics companies. Use of high-sensitivity troponins as part of the HEART Pathway system has been a major step forward in terms of sensitivity and safety. “High-sensitivity troponins really add value to the HEART Pathway,” Mahler observes. “They are better able to detect patients that are having myocardial injury, so we’re less likely to miss a patient that’s having a heart attack. We are probably sending more patients home now with the high-sensitivity troponins incorporated into our HEART Pathway then we were previously.”
Simon Mahler, MD
The team is continuously working on the system, updating and upgrading as new information becomes available, particularly in the rapidly advancing science related to the high-sensitivity troponins. “We went on to high-sensitivity troponins just one year ago, so we are still gathering the data, evaluating it, and making decisions about our algorithm as to whether or not we need to make further adjustments,” says Mahler. “That is something that will be happening in the future, and we may be looking at other tweaks to the score itself as we move forward, to determine the best balance in terms of efficiency, and of course the key is maintaining safety. But the high-sensitivity troponins add a margin of safety on the laboratory side, so we may be able to change some of the features of the HEART Pathway to correctly account for the safety while ramping up the number of patients that are able to be sent home. Fine-tuning the system to optimize it for high-sensitivity troponins is still an ongoing process as the data is coming in.”
The Next Frontier: Pre-hospital
The HEART Pathway scientists are now working on studies applying a modified version of the system in the ambulance-based, pre-hospital setting. They recently published an article in PLOS ONE reporting on a study exploring the use of a pre-hospital modified HEART Pathway (PMHP). PMHP takes the concepts of the HEART Pathway and fits them to the pre-hospital model to improve triage of patients by paramedics when they are first evaluating chest pain patients. The study showed that paramedics were able to effectively risk-stratify patients using PMHP.
Mahler explains: “In the pre-hospital space, the main thing the paramedics have been trained to do is to look for something called a STEMI [ST-segment elevation myocardial infarction]—the widow-maker heart attack where somebody has to go immediately to the cath lab and get opened up.”
But STEMIs are present in only seven percent of patients with chest pain transported to the hospital by EMS. With patients who are not having a STEMI, the emergency personnel often will just take that person to the nearest hospital, without regard to the individual’s level of risk—high, moderate or low. That can result in unnecessary delays, medical costs and utilization. “If we can recognize that up front by applying the PMHP, we can get that patient to the right place at the right time,” says Mahler. “For example, a low-risk patient transported to the ED is not going to have any benefit from going to the ED, and will potentially face a very long wait and increased expenses. If we can get them to the right place instead, which is more of a clinic visit, we can save them a lot of their time and money and get them plugged into the primary care they need.”
“The concept of the academic learning health system is a health system that collects data on things that have benefited our patients and then learns from that and changes, and that is precisely what we’ve done with HEART Pathway.”
Simon Mahler, MD
Changing the World of Chest Pain
Mahler is justifiably proud of the work he and his colleagues have done to develop and continuously improve the HEART Pathway system.
“When you go back to 2010 and ’11, I think most of us who were practicing emergency medicine felt we could do more for patients with chest pain. We knew we were admitting too many patients. We knew we were stress testing a large number of patients, but we just didn’t know what to do, because there was plenty of evidence that despite all of that testing, we were still missing people. So it’s been really gratifying to see the work that we’ve done spread throughout the country and really help patients and providers,” he says.